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ASSOCIATION BETWEEN SOCIOECONOMIC CHARACTERISTICS AND CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA TREATMENT- AND SURVIVAL-RELATED OUTCOMES IN CANADA
Abstract
Background and Aims
Cure rates for childhood acute lymphoblastic leukemia (ALL) currently exceed 90% with optimum and timely therapy. Previous research has found that lower socioeconomic status (SES) is associated with longer times to diagnosis and treatment, and poorer adherence to treatment, resulting in poorer health- and survival-related outcomes. Findings however have been inconsistent. We aimed to determine if in Canada, SES is associated with risk at diagnosis, time to diagnosis, time to treatment, event-free survival (EFS), and overall survival (OS) in children with ALL.
Methods
We conducted a retrospective cohort study of all children aged <15 years diagnosed with first primary ALL between 2001 and 2016 using the Cancer in Young People in Canada national registry. SES was measured using neighbourhood income quintiles at time of diagnosis. We used logistic regression to examine the associations between income quintile and two indicators of high-risk ALL at diagnosis, white blood cell count (WBC) ≥50 x 109/L and central nervous system (CNS) involvement. We used Cox proportional hazards to examine associations between income quintile and time-to-event outcomes.
Results
3,891 patients were included. No association was found between income quintile and indicators of high risk at diagnosis, time to diagnosis, or time to treatment. Compared to those in the lowest income quintile, children in some higher quintiles experienced superior EFS (Q2 hazard ratio (HR): 0.74, 95% CI: 0.55-0.98 and Q4 HR: 0.74, 95% CI: 0.56-0.98). EFS for children in other income quintiles were however not statistically different from those in the lowest. Associations for OS were similar to EFS in magnitude although not statistically significant.
Conclusions
Children diagnosed with ALL in Canada experience similar times to diagnosis and treatment and have the same odds of having high WBC and CNS involvement at diagnosis, regardless of SES. However, event-free survival may be inferior among children from the lowest income neighbourhoods.
IMPACT OF MICRONUTRIENT DEFICIENCY ON OUTCOME IN CHILDREN WITH CANCER
Abstract
Background and Aims
Micronutrient deficiency and its impact on outcome in children with cancer is not well explored. We evaluated the role of baseline deficiency of vitamin B12, folic acid, selenium, copper, zinc and iron on outcome of paediatric malignancies.
Methods
A prospective study was conducted between October 2012-October 2016 where treatment naïve children (≤18 years) with diagnosis of cancer were included. Baseline serum levels of following micronutrients were measured: vitamin B12 (solid-phase competitive chemiluminescent immunoassay), folic acid (competitive chemiluminescent immunoassay), copper (mass spectrometry), zinc (mass spectrometry), selenium (mass spectrometry) and iron (ferrozine method without deproteinization). Values of vitamin B12, folic acid, selenium, copper, zinc and iron below 147.7 pmol/L, 12 nmol/L, 0.6 µmol/L, 14.1 µmol/L, 11.3 µmol/L and 8.9 µmol/L respectively were considered as deficient. The mortality, infection-related mortality, event free survival (EFS) and overall survival (OS) of deficient group were compared with normal group.
Results
Total 539 patients were included with median age of 10 years [55.7%: haematological, 44.3%: solid malignancies]. Patients deficient in serum vitamin B12, folic acid, copper, zinc, selenium and iron were 169(33.9%), 91(16.9%), 36(6.7%), 246(45.6%), 71(13.2%) and 235(43.6%) respectively. Children with zinc deficiency were more likely to have mortality (OR=1.45;p=0.03), shorter OS (HR=1.32;p=0.03) and trend towards shorter EFS (HR=1.27;p=0.06). Children with selenium deficiency also had shorter EFS (HR=1.42;p=0.04), shorter OS (HR=1.44;p=0.03) and trend towards increased mortality (OR=1.64;p=0.05). In haematological malignancies, serum selenium deficiency was associated with increased mortality (OR=1.95;p=0.03), shorter EFS (HR=1.53;p=0.04) and OS (HR=1.61;p=0.02).; while, in solid malignancies, serum zinc deficiency was associated with increased mortality (OR=2.34;p=0.002), shorter EFS (HR=1.84;p=0.002) and OS (HR=2.03;p<0.001). Children with multiple micronutrient deficiencies (>3) also had increased mortality (OR=2.25;p=0.02) and shorter OS (HR=1.82;p=0.008). Micronutrient deficiency did not impact infection-related mortality.
Conclusions
Deficiency of micronutrients, especially selenium and zinc, have an impact on outcome in children with cancer.
THE COST-EFFECTIVENESS OF TREATING CHILDHOOD CANCER IN SUB-SAHARAN AFRICA: RESULTS FROM A MULTICENTRE STUDY ACROSS FOUR COUNTRIES
Abstract
Background and Aims
Background: Childhood cancer treatment is often assumed to be costly in African settings, limiting advocacy and policy efforts. We determined the cost and cost-effectiveness of maintaining childhood cancer centres across four hospitals throughout Sub-Saharan Africa.
Methods
Methods: Within hospitals representing four countries (Kenya, Nigeria, Tanzania, Zimbabwe), cost was determined (retrospectively or prospectively) for all inputs related to operating a paediatric cancer unit (e.g. laboratory, medications, salaries). Cost-effectiveness was calculated based on annual newly diagnosed patients, survival rates, and life expectancy.
Results
Results: Cost per new diagnosis ranged from $2,400-$31,000, attributable to variance in centre size, case mix, drug prices, admission practices, and abandonment rate, which also affected survival. The most expensive cost input was associated with medication in Kenya, and medical personnel in the other three centres. The cost per disability-adjusted life-year (DALY) averted ranged from 0.3 to 3.6 times per capita Gross National Income. Childhood cancer treatment was therefore considered very cost-effective by World Health Organization standards in two countries and cost-effective in one additional country. In all centres, abandonment of therapy was common; modelling exercises suggested that public funding of treatment, additional psychosocial personnel, and modifications of inpatient policies would increase survival rates while maintaining or even improving cost-effectiveness.
Conclusions
Conclusions: Across various African contexts, childhood cancer treatment units represent cost-effective interventions. Cost-effectiveness can be increased through drug prices control, appropriate policy environments, and decreasing abandonment. These results will inform national childhood cancer strategies across Africa.
MEDIAN TIME TO DIAGNOSIS FOR MOST CHILDHOOD CANCERS IS LONGER IN LOW/MIDDLE-INCOME COUNTRIES COMPARED TO HIGH–INCOME COUNTRIES: RESULTS OF A SYSTEMATIC REVIEW AND META-ANALYSIS
Abstract
Background and Aims
Literature suggests that barriers to timely diagnosis and treatment are likely to be higher in low-income (LIC) and middle-income countries (MIC) compared to high-income countries (HIC). Time to diagnosis (TTD), defined as the length of time between symptom onset and the final diagnosis is a metric which can be used to quantify and explore such barriers. We therefore aimed to investigate the variation in TTD in weeks for a country’s economic status (HIC vs LIC/MIC).
Methods
A systematic search of literature published before Dec 2017 and containing TTD data for childhood cancers was conducted through several databases and complimented with searching reference lists of included studies. Two researchers independently did study selection and data extraction. Descriptive analysis as well as meta-analysis using random effects of cancer type or subtype with > 5 studies with median TTD was done. Quality assessment was conducted using the Aarhus checklist where appropriate.
Results
Of the 3493 studies screened, 192 studies were included (116 HIC, 72 MIC, 6 LIC) which had 304 median TTD for one or more childhood cancers. The median TTD in LIC/MIC was longer compared to HIC for most childhood cancers except for bone sarcomas, germ cell tumours and carcinomas. The differential was six-fold for ALL (1.08 weeks HIC vs 6.49 weeks LIC/MIC), four-fold for AML (1.45 vs 6.68) and Wilms tumour (1.78 vs 7.96), and three-fold for medulloblastoma (6.04 vs 21.7). Majority of the studies did not fulfil the Aarhus checklist criteria but did provide clear definitions of the time interval to diagnosis.
Conclusions
This analysis is the largest body of work on median TTD in children with cancer till date and the first to attempt contrasting this metric among HIC vs LIC/LMIC. The longer median TTD for most cancers may partly explain a more advanced stage at presentation in LMIC and poorer outcomes.
COVID-19 IN PEDIATRIC HEMATOLOGY AND ONCOLOGY PATIENTS IN NEW YORK CITY
- Bradley Gampel, United States of America
- Alexandre G. Troullioud Lucas, United States of America
- Larisa Broglie, United States of America
- Robyn D. Gartrell-Corrado, United States of America
- Margaret T. Lee, United States of America
- Jennifer Levine, United States of America
- Manuela Orjuela-Grimm, United States of America
- Prakash Satwani, United States of America
- Julia Glade Bender, United States of America
- Stephen Roberts, United States of America
Abstract
Background and Aims
Little is known about Covid-19 disease in pediatric hematology, oncology and hematopoietic cell transplant (HCT) patients. New York City (NYC), the epicenter of Covid-19 infection in the United States, can provide valuable data in this population. We describe the characteristics and clinical course of Covid-19 disease in patients treated at our centers.
Methods
We identified all patients tested for Covid-19, ages 0-21 years, and cared for by pediatric hematology, oncology, and HCT services at Memorial Sloan Kettering Cancer Center (MSK) and New York Presbyterian Hospital (NYP, Columbia University Irving Medical Center and Weill Cornell Medical Center) through April 6, 2020. Demographic, clinical course, and outcomes were identified and descriptively summarized for Covid-19 positive patients.
Results
Patients (n=174) were tested for Covid-19 at MSK (n=120, all patients were screened) and NYP (n = 54, ‘at risk’ patients were screened); nineteen tested positive (11%), males > females (adjusted Odds Ratio 3.1). Three had non-malignant hematologic diagnoses, fourteen had cancer, and two were post-HCT. The most common presenting symptoms were fever (n=13), cough (n=9), and difficulty breathing (n=7). Nine of fourteen cancer patients (64%) experienced treatment delays due to Covid-19 positivity. Eleven patients were hospitalized; five required intensive care, including one with sickle cell disease who died of Covid-19 related complications. No Covid-19 positive patients who were initially managed as outpatients subsequently required admission.
Conclusions
The majority of patients had mild disease and many were managed as outpatients. Males appeared to have a higher incidence of infection compared to females. Covid-19 led to treatment delays in most cancer patients, however those who received myelosuppressive chemotherapy during and prior to infection did not appear to have increased complications. Oncologic patients without underlying comorbidities beyond their cancer do not appear to have a greater risk of complications from Covid-19 than other children.